ID

5840

Beskrivning

Diagnostic Imaging Report LOINC 18748-4 converted from CDA template

Nyckelord

  1. 2014-09-30 2014-09-30 - Martin Dugas
Uppladdad den

30 september 2014

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0 Legacy

Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Itemgroup-kommentar för :

Item-kommentar för :

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

Diagnostic Imaging Report (CDA)

Diagnostic Imaging Report (CDA)

  1. StudyEvent: Chest X-Ray, PA and LAT View
    1. Diagnostic Imaging Report (CDA)
ClinicalDocument
Beskrivning

ClinicalDocument

Title of Report
Beskrivning

Title of Report

Datatyp

text

Given name
Beskrivning

Given name (recordTarget.patientRole.patient.name.given)

Datatyp

text

Alias
UMLS CUI-1
C1299487
Family name (recordTarget.patientRole.patient.name.family)
Beskrivning

Family name (recordTarget.patientRole.patient.name.family)

Datatyp

text

Alias
UMLS CUI-1
C0421448
Patient gender
Beskrivning

Patient gender (recordTarget.patientRole.patient.administrativeGenderCode.code)

Datatyp

text

Alias
UMLS CUI-1
C0079399
Date of Birth (recordTarget.patientRole.patient.birthTime.value)
Beskrivning

Date of Birth (recordTarget.patientRole.patient.birthTime.value)

Datatyp

date

Alias
UMLS CUI-1
C0421451
Documentation time (author.time.value)
Beskrivning

Documentation time (author.time.value)

Datatyp

time

Document author given name (author.assignedAuthor.assignedPerson.name.given)
Beskrivning

Document author given name (author.assignedAuthor.assignedPerson.name.given)

Datatyp

text

Document author family name (author.assignedAuthor.assignedPerson.name.family)
Beskrivning

Document author family name (author.assignedAuthor.assignedPerson.name.family)

Datatyp

text

Information recipient given name (informationRecipient.intendedRecipient.informationRecipient.name.given)
Beskrivning

Information recipient given name (informationRecipient.intendedRecipient.informationRecipient.name.given)

Datatyp

text

Information recipient family name (informationRecipient.intendedRecipient.informationRecipient.name.family)
Beskrivning

Information recipient family name (informationRecipient.intendedRecipient.informationRecipient.name.family)

Datatyp

text

Service event code
Beskrivning

Service event code (documentationOf.serviceEvent.code.attributes.code), e.g. 70544 from codeSystemname CPT4

Datatyp

text

Service event name (documentationOf.serviceEvent.code.attributes.displayName), e.g. Magnetic resonance angiography, head; without contrast material(s)
Beskrivning

Service event name (documentationOf.serviceEvent.code.attributes.displayName), e.g. Magnetic resonance angiography, head; without contrast material(s)

Datatyp

text

Date and time of service event (documentationOf.serviceEvent.effectiveTime.low.value)
Beskrivning

Date and time of service event (documentationOf.serviceEvent.effectiveTime.low.value)

Datatyp

datetime

Performing entity code (documentationOf.serviceEvent.performer.assignedEntity.code.attributes.code)
Beskrivning

Performing entity code (documentationOf.serviceEvent.performer.assignedEntity.code.attributes.code)

Datatyp

text

Performing entity name (documentationOf.serviceEvent.performer.assignedEntity.code.displayName), e.g. Diagnostic Radiology
Beskrivning

Performing entity name (documentationOf.serviceEvent.performer.assignedEntity.code.displayName), e.g. Diagnostic Radiology

Datatyp

text

Performer given name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.given)
Beskrivning

Performer given name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.given)

Datatyp

text

Performer family name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.family)
Beskrivning

Performer family name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.family)

Datatyp

text

Modality code (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.code), e.g. CR
Beskrivning

Modality code (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.code), e.g. CR

Datatyp

text

Modality name (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.displayName), e.g. Computed Radiography
Beskrivning

Modality name (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.displayName), e.g. Computed Radiography

Datatyp

text

Storage System Code (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.codeSystemName), e.g. DCMUID
Beskrivning

Storage System Code (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.codeSystemName), e.g. DCMUID

Datatyp

text

Storage System Name (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.attributes.displayName), e.g. Computed Radiography Image Storage
Beskrivning

Storage System Name (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.attributes.displayName), e.g. Computed Radiography Image Storage

Datatyp

text

Reference to image (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.text.reference.attributes.value)
Beskrivning

Reference to image (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.text.reference.attributes.value)

Datatyp

text

Indications for procedure (component.structuredBody.component.section.text)
Beskrivning

Indications for procedure (component.structuredBody.component.section.text)

Datatyp

text

Medical history (component.structuredBody.component.section.text.paragraph.content)
Beskrivning

Medical history (component.structuredBody.component.section.text.paragraph.content)

Datatyp

text

Alias
UMLS CUI-1
C0262926
Findings (component.structuredBody.component.section.text.paragraph.content)
Beskrivning

Findings (component.structuredBody.component.section.text.paragraph.content)

Datatyp

text

Alias
UMLS CUI-1
C0243095
Finding ID (component.structuredBody.component.section.text.paragraph.content.attributes.ID)
Beskrivning

Finding ID (component.structuredBody.component.section.text.paragraph.content.attributes.ID), e.g. Diam2

Datatyp

text

Finding value (component.structuredBody.component.section.text.paragraph.content)
Beskrivning

Finding value (component.structuredBody.component.section.text.paragraph.content), e.g. 45mm

Datatyp

text

Alias
UMLS CUI-1
C0243095
Source of Measurement (component.structuredBody.component.section.text.paragraph.content.linkHtml.href), Link to source
Beskrivning

Source of Measurement (component.structuredBody.component.section.text.paragraph.content.linkHtml.href), Link to source

Datatyp

text

Impression (component.structuredBody.component.section.text.paragraph.content)
Beskrivning

Impression (component.structuredBody.component.section.text.paragraph.content)

Datatyp

text

Alias
UMLS CUI-1
C1998467

Similar models

Diagnostic Imaging Report (CDA)

  1. StudyEvent: Chest X-Ray, PA and LAT View
    1. Diagnostic Imaging Report (CDA)
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Title of Report
Item
Title of Report
text
Patient name
Item
Given name
text
C1299487 (UMLS CUI-1)
Patient surname
Item
Family name (recordTarget.patientRole.patient.name.family)
text
C0421448 (UMLS CUI-1)
Gender
Item
Patient gender
text
C0079399 (UMLS CUI-1)
Date of Birth
Item
Date of Birth (recordTarget.patientRole.patient.birthTime.value)
date
C0421451 (UMLS CUI-1)
Documentation time
Item
Documentation time (author.time.value)
time
Document author given name
Item
Document author given name (author.assignedAuthor.assignedPerson.name.given)
text
Document author family name
Item
Document author family name (author.assignedAuthor.assignedPerson.name.family)
text
Information recipient given name
Item
Information recipient given name (informationRecipient.intendedRecipient.informationRecipient.name.given)
text
Information recipient family name
Item
Information recipient family name (informationRecipient.intendedRecipient.informationRecipient.name.family)
text
Service event code
Item
Service event code
text
Service event name
Item
Service event name (documentationOf.serviceEvent.code.attributes.displayName), e.g. Magnetic resonance angiography, head; without contrast material(s)
text
Date and time of service event
Item
Date and time of service event (documentationOf.serviceEvent.effectiveTime.low.value)
datetime
Performing entity code
Item
Performing entity code (documentationOf.serviceEvent.performer.assignedEntity.code.attributes.code)
text
Performing entity name
Item
Performing entity name (documentationOf.serviceEvent.performer.assignedEntity.code.displayName), e.g. Diagnostic Radiology
text
Performer given name
Item
Performer given name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.given)
text
Performer family name
Item
Performer family name (documentationOf.serviceEvent.performer.assignedEntity.assignedPerson.name.family)
text
Modality code
Item
Modality code (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.code), e.g. CR
text
Modality name
Item
Modality name (component.structuredBody.component.section.entry.act.entryRelationship.act.code.qualifier.value.attributes.displayName), e.g. Computed Radiography
text
Storage System Code
Item
Storage System Code (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.codeSystemName), e.g. DCMUID
text
Storage System Name
Item
Storage System Name (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.code.attributes.displayName), e.g. Computed Radiography Image Storage
text
Reference to image
Item
Reference to image (component.structuredBody.component.section.entry.act.entryRelationship.act.entryRelationship.observation.text.reference.attributes.value)
text
Indications for procedure
Item
Indications for procedure (component.structuredBody.component.section.text)
text
Medical history
Item
Medical history (component.structuredBody.component.section.text.paragraph.content)
text
C0262926 (UMLS CUI-1)
Findings
Item
Findings (component.structuredBody.component.section.text.paragraph.content)
text
C0243095 (UMLS CUI-1)
Finding ID
Item
Finding ID (component.structuredBody.component.section.text.paragraph.content.attributes.ID)
text
Finding value
Item
Finding value (component.structuredBody.component.section.text.paragraph.content)
text
C0243095 (UMLS CUI-1)
Source of Measurement
Item
Source of Measurement (component.structuredBody.component.section.text.paragraph.content.linkHtml.href), Link to source
text
Impression
Item
Impression (component.structuredBody.component.section.text.paragraph.content)
text
C1998467 (UMLS CUI-1)

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial